Articles

Magnitude, temporal trends, and projections of the global

prevalence of blindness and distance and near vision
impairment: a systematic review and meta-analysis
Rupert R A Bourne*, Seth R Flaxman*, Tasanee Braithwaite, Maria V Cicinelli, Aditi Das, Jost B Jonas, Jill Keeffe, John H Kempen, Janet Leasher,
Hans Limburg, Kovin Naidoo, Konrad Pesudovs, Serge Resnikoff, Alex Silvester, Gretchen A Stevens, Nina Tahhan, Tien Y Wong, Hugh R Taylor,
on behalf of the Vision Loss Expert Group

Summary
Background Global and regional prevalence estimates for blindness and vision impairment are important for the Lancet Glob Health 2017;
development of public health policies. We aimed to provide global estimates, trends, and projections of global 5: e888–97

blindness and vision impairment. Published Online

August 2, 2017
http://dx.doi.org/10.1016/
Methods We did a systematic review and meta-analysis of population-based datasets relevant to global vision S2214-109X(17)30293-0
impairment and blindness that were published between 1980 and 2015. We fitted hierarchical models to estimate the See Comment page 843
prevalence (by age, country, and sex), in 2015, of mild visual impairment (presenting visual acuity worse than 6/12 to *These authors contributed
6/18 inclusive), moderate to severe visual impairment (presenting visual acuity worse than 6/18 to 3/60 inclusive), equally to the research and
blindness (presenting visual acuity worse than 3/60), and functional presbyopia (defined as presenting near vision manuscript and are listed as
worse than N6 or N8 at 40 cm when best-corrected distance visual acuity was better than 6/12). senior authors
Vision & Eye Research Unit,
Anglia Ruskin University,
Findings Globally, of the 7·33 billion people alive in 2015, an estimated 36·0 million (80% uncertainty interval [UI] Cambridge, UK
12·9–65·4) were blind (crude prevalence 0·48%; 80% UI 0·17–0·87; 56% female), 216·6 million (80% UI (R R A Bourne MD,
98·5–359·1) people had moderate to severe visual impairment (2·95%, 80% UI 1·34–4·89; 55% female), and T Braithwaite MPH);
188·5 million (80% UI 64·5–350·2) had mild visual impairment (2·57%, 80% UI 0·88–4·77; 54% female). Department of Statistics,
University of Oxford, Oxford,
Functional presbyopia affected an estimated 1094·7 million (80% UI 581·1–1686·5) people aged 35 years and UK (S R Flaxman BA);
older, with 666·7 million (80% UI 364·9–997·6) being aged 50 years or older. The estimated number of blind San Raffaele Scientific
people increased by 17·6%, from 30·6 million (80% UI 9·9–57·3) in 1990 to 36·0 million (80% UI 12·9–65·4) Institute, Milan, Italy
in 2015. This change was attributable to three factors, namely an increase because of population growth (38·4%), (M V Cicinelli MD); Health
Education England (Yorkshire
population ageing after accounting for population growth (34·6%), and reduction in age-specific and the Humber), Leeds, UK
prevalence (–36·7%). The number of people with moderate and severe visual impairment also increased, from (A Das MD); Department of
159·9 million (80% UI 68·3–270·0) in 1990 to 216·6 million (80% UI 98·5–359·1) in 2015. Ophthalmology,
Universitätsmedizin,
Mannheim, Medical Faculty
Interpretation There is an ongoing reduction in the age-standardised prevalence of blindness and visual impairment, Mannheim, Heidelberg
yet the growth and ageing of the world’s population is causing a substantial increase in number of people affected. University, Mannheim,
These observations, plus a very large contribution from uncorrected presbyopia, highlight the need to scale up vision Germany (J B Jonas MD);
L V Prasad Eye Institute,
impairment alleviation efforts at all levels.
Hyderabad, India (J Keeffe PhD);
Immunology and Uveitis
Funding Brien Holden Vision Institute. Service, Department of
Ophthalmology,
Massachusetts Eye and Ear
Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.
Infirmary, Boston, MA, USA
(J H Kempen MD); Discovery Eye
Introduction data from population-based studies that reported the Center, MyungSung Christian
Universal Eye Health: a Global Action Plan 2014–2019 prevalence of blindness and vision impairment from Medical Center, Addis Ababa,
Ethiopia (J H Kempen); Nova
was adopted by WHO member states at the World Health 1980, using a continuously updated database of
Southeastern University,
Assembly in 2013.1 Its goals are to reduce vision population-based studies (the Global Vision Database). Fort Lauderdale, FL, USA
impairment as a global public health problem and to Globally, we estimated that 32·4 million people were (J Leasher OD); Health
secure access to rehabilitation for people with vision blind in 2010, and that 191 million people had moderate Information Services,
Grootebroek, Netherlands
impairment. The initiative has the global target of and severe vision impairment. Additionally, the age-
(H Limburg PhD); African Vision
reducing the prevalence of avoidable vision impairment standardised prevalence of blindness and moderate and Research Institute, University
by 25% from 2010 to 2019. One of the key objectives of severe vision impairment decreased between 1990 of Kwazulu-Natal, Durban,
the Global Action Plan is to generate evidence on the and 2010.2 Country-specific data were made available South Africa (K Naidoo PhD);
Brien Holden Vision Institute,
magnitude of vision impairment, which is required to online, searchable by level of vision impairment, age, Sydney, NSW, Australia
evaluate the success of this and similar initiatives. and sex. (K Naidoo, S Resnikoff MD,
Previously, we reported the results of a systematic Vision impairment and age-related eye diseases affect N Tahhan PhD); NHMRC Centre
review of published literature and some unpublished economic and educational opportunities,3 reduce for Clinical Eye Research,

www.thelancet.com/lancetgh Vol 5 September 2017 e888

 Articles
Flinders University, Adelaide,
SA, Australia (K Pesudovs PhD);
School of Optometry and
Vision Science, University of
New South Wales, Sydney,
NSW, Australia (S Resnikoff,
N Tahhan); St Paul’s Eye Unit,
Royal Liverpool University
Hospital, Liverpool, UK
(A Silvester MD); Department of
Information, Evidence and
Research, World Health
Organization, Geneva,
Switzerland (G A Stevens DSc);
Singapore Eye Research
Institute, Duke-NUS Graduate
Medical School, National
University of Singapore,
Singapore (T Y Wong PhD); and
Melbourne School of
Population Health, University
of Melbourne, Carlton, VIC,
Australia (H R Taylor MD)
Correspondence to:
Prof Rupert Bourne, Vision & Eye
Research Unit, Anglia Ruskin
University, Cambridge CB1 1PT,
UK
rb@rupertbourne.co.uk
See Online for appendices
For more on the Global Vision
Database see http://www.
globalvisiondata.org
e889 www.thelancet.com/lancetgh Vol 5 September 2017
Research in context
Evidence before this study
The first systematic review of published literature (1980–2012)
involved extraction of data on both presenting and
best-corrected visual acuity from only population-based studies
that reported prevalence of vision impairment and a definition
of vision impairment for which we could develop a method for
inclusion. These data formed the Global Vision Database from
which estimates for global prevalence of vision impairment and
blindness were calculated for 2010. This was the most
comprehensive global meta-analysis of its kind, with important
advances on previous WHO reports that had not investigated
sex differences or age distributions in blindness and vision
impairment. The study also permitted, for the first time, a
temporal analysis from 1990 to 2010 that showed a decline in
the age-standardised prevalence of blindness and vision
impairment, but an increase in crude prevalence (due to
population growth and ageing).
Added value of this study
This study updates the global, regional, and country-level
blindness and vision impairment prevalence estimates to 2015,
incorporating important developments since 2010, namely
more data sources (61 new studies from 35 different countries)
including more precise data (individual-level data for many
quality of life,4 and increase the risk of death.5,6
Previously, we reported principally on blindness and
moderate and severe vision impairment, with minimal
detail beyond a global estimate for mild vision
impairment because data were sparse for this vision
impairment category, in which a person has a
presenting (with usual optical correction) visual acuity
less than 6/12 but 6/18 or better in the better eye.7 This
degree of vision impairment, despite being classified as
mild, has a substantial effect on quality of life. For
example, in many countries, an individual with this
level of vision would be barred from driving.8
Uncorrected presbyopia is the most common cause of
vision impairment,9 hence WHO has recommended
measurement of near vision in population-based surveys
(eg, the Consultation on development of standards for
characterization of vision loss and visual functioning in
2003). In some contexts, impairment of near vision is at
least as detrimental to quality of life as impairment of
distance vision, regardless of the environment, lifestyle,
or sociodemographic status of the affected individuals.10
Improvements to the Global Vision Database that
broadened its capabilities enabled us to provide global
estimates of the 2015 global burden of vision
impairment, including functional presbyopia; to report
trends in vision impairment from 1990 to 2015 by
country, sex, and age; and to make projections to 2020
and 2050 regarding the number of people with vision
impairment.
studies), improved statistical analysis, the inclusion of
estimates of functional presbyopia, and projections of
blindness and vision impairment burden to 2020 and 2050.
Implications of all the available evidence
Our study has shown that in 2015, an estimated 36 million
people were blind, 217 million were moderately or severely
vision impaired, and 188 million had mild vision impairment.
1·09 billion people aged 35 years or older are affected by
near-vision impairment due to uncorrected presbyopia.
The interval improvement (in terms of a reduction in
prevalence of distance vision impairment) since 1990
and 2010, after accounting for population growth and ageing,
suggests that investments made in the alleviation of vision
impairment during this period have reaped considerable
dividends. Such dividends would include improvements in
quality of life, and large economic benefits as people work
rather than living with unnecessary disability. Yet the growth
and change in age structure of the world’s population is causing
a substantial increase in the number of people with blindness
and vision impairment, which appears to be accelerating.
This finding highlights the need to scale up our current efforts
at global, regional, and country level.
Methods
Study design
Using data from the Global Vision Database, we
estimated trends in prevalence of vision impairment
and their uncertainties, by sex, for 188 countries in the
21 Global Burden of Disease (GBD) regions, from 1990
to 2015 (appendix 1). Using definitions and an analytical
framework similar to that of our previous publication2
(appendix 1), we used statistical models to estimate the
prevalence of two of the core categories of vision
impairment: blindness (presenting visual acuity worse
than 3/60) and a combined grouping called moderate
and severe vision impairment (presenting visual acuity
worse than 6/18 to 3/60 inclusive; table 1).2 We did our
analysis in seven steps: data identification and
extraction; conversion of vision impairment data to two
core levels (blindness and moderate and severe vision
impairment); estimation of age-specific vision
impairment prevalence when data were not reported by
age; selection and use of a statistical model to estimate
the prevalence of blindness and moderate and severe
vision impairment by country, age, sex, and year;
estimation of severe, moderate, and mild vision
impairment based on crosswalk from our estimates of
blindness and moderate and severe vision impairment;
estimation of functional presbyopia prevalence; and
forecasting of prevalence of blindness and vision
impairment to 2020 and 2050.

Data identification and extraction
We commissioned a systematic review of population-
based studies published between Jan 1, 1980, and July 8,
2014, by York Health Economics Consortium and
unpublished data identified by members of the Vision
Loss Expert Group who convened for the 2010 GBD study,
to find data on distance vision impairment.
Our systematic review used the same search terms of a
previous systematic review,7 but we extended the review
to include studies published up to July 8, 2014
(appendix 1). The methods for this extended systematic
review are described in appendix 1 as a PRISMA
flowchart and checklist.
Briefly, studies that were included in the Global Vision
Database met the following requirement criteria. Reported
prevalence of blindness, visual impairment, or both, was
measured from random sample cross-sectional surveys of
representative populations of any age of a country or area
of a country. Studies using hospital or clinic case series,
blindness registries, and interview studies with self-
reported vision status were not included. Definitions of
visual impairment or blindness were clearly stated, used
thresholds of visual acuity in the better eye that matched
or could be later modelled to match the definitions given
in appendix 1. Best-corrected or presenting visual acuity
was stated. Procedures used for measurement of visual
acuity were clearly stated. We extracted data on both
presenting and best-corrected visual acuity. Appendix 1
includes a full list of data sources for distance blindness,
vision impairment, and presbyopia.
Conversion to core definitions of visual acuity
Similar to the strategy in our previous systematic review,2
we standardised all prevalence data to the definitions of
vision impairment selected for this study (appendix 1).
We used four regressions to convert two commonly used
definitions of blindness (visual acuity <6/60 and visual
acuity ≤6/60) to our definition of blindness, and to
convert two commonly reported definitions of vision
impairment (visual acuity <6/18 and visual acuity <6/12)
to our definition of moderate and severe vision
impairment (appendix 1).
Estimation of age-specific data
Our statistical model is based on the age-specific prevalence
of vision impairment for 5-year age intervals (eg, 20–24-year-
olds). In cases when studies reported the prevalence of
vision impairment for a wider age group—such as all ages
or adults older than 50 years—we converted these to 5-year
age groups as follows. We fitted two universal age patterns,
one for the prevalence of blindness and one for the
prevalence of moderate and severe vision impairment,
meta-analysing from aggregated studies that reported
prevalence for the narrower age groups. We then applied
the fitted age patterns to the wide age group aggregated
dataset, to calculate prevalence by 5-year age intervals. We
ensured that the age-specific prevalence values summed to
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Articles
Presenting visual acuity* in the better eye
Mild vision impairment <6/12 but 6/18 or better
Moderate and severe <6/18 but 3/60 or better
vision impairment
Blindness <3/60
Presbyopia Near vision worse than N6 or N8 at 40 cm and
best corrected visual acuity ≥6/12 (20/40)
*Snellen visual acuity or the equivalent calculated from published logarithm of
the minimum angle of resolution values.
Table 1: Categories of vision impairment with corresponding visual acuity
the reported wide age range prevalence when weighted by
the country’s population by age. Further details are
available in appendix 1.
Statistical analysis of vision impairment data
We fitted two hierarchical Bayesian logistic regressions
to estimate vision impairment prevalence over time, by
age group, sex, and country, with one model for the
prevalence of blindness and one model for the prevalence
of moderate and severe vision impairment. Using fully
Bayesian statistical inference,11 our posterior estimates of
vision impairment were able to flexibly borrow strength
such that country-specific estimates were informed by
study data from the same country, where available, and
by study data from other countries in the same region or
the same year. Variance parameters for the random and
fixed effects in the model, which were themselves
assigned prior values, enabled the model to flexibly learn
the degree to which data were pooled between countries
in the same region and over time.
We used a model in which vision impairment levels in
countries were modelled hierarchically to be nested into
each of the 21 GBD regions, which were in turn nested in
the seven GBD world super-regions (appendix 1). We
modelled hierarchical linear trends over time, allowing for
region-specific trends in prevalence of vision impairment
in the seven world super-regions. A sex effect was likewise
modelled hierarchically by seven world super-regions,
thus allowing for differences in sex disparities by region.
We modelled age as a three-piece linear spline with knots
at age 40 years and age 70 years.
To account for potential variability resulting from non-
homogeneous study designs and from some studies
being only subnationally or locally representative, we
included study-specific error terms, which we interacted
with an indicator of whether the study was national or
not. This approach permitted nationally representative
studies to have a greater influence on estimates. We also
included a fixed effect indicator for urban versus rural
studies. We included a fixed effect indicator for whether
the study measured prevalence on the basis of best-
corrected or presenting distance visual acuity, and we
allowed this difference to vary in the south Asia region,
for reasons we have previously described.2
 Articles
To help with issues of data sparsity, we included two
time-varying covariates: mean years of adult education by
age group12 and an index of access to health care.13 Our
model was developed on the basis of previous work and
on the leave-one-out measure of model fit similar to
cross-validation.14,15
We fitted our blindness and moderate and severe vision
impairment models using Bayesian inference, sampling
from the posterior distribution over the parameters
using Hamiltonian Monte Carlo, a Markov chain
Monte Carlo method, as implemented in the RStanArm
For more on Stan see package (version 2.11.1), which relies on Stan.16 We used a
http://mc-stan.org leave-one-out measure to assess model fit and compare
various modelling specifications (appendix 1).
Each model was run with four chains for 1000 iterations
each, with 500 warm-up iterations. After fitting the
model, posterior predictions were made for each country–
year–age–sex group. Prevalence estimates are given in the
context of 80% uncertainty intervals (UIs). Complete
details of our model and a graphical representation of the
model fits are provided in appendix 1.
Estimation of visual impairment
We fitted logistic regressions to convert the prevalence of
blindness and moderate and severe vision impairment to
mild, moderate, and severe vision impairment (appendix
1), and applied the logistic regressions to each sampled
prediction drawn from the Bayesian posterior, thus
obtaining a set of samples of mild, moderate, and severe
vision impairment by country–year–age–sex group. To
obtain global and regional estimates, we calculated the
means and the tenth and 90th percentiles of the posterior
uncertainty intervals for each country prediction, age, and
sex, then we combined these, weighting each country
prediction by its population in the relevant age–sex
category. We also reported age-standardised estimates
using the WHO reference population,17 and the raw
numbers of people with vision impairment by category.
We calculated trends of age-standardised vision impair­
ment by world region, with UIs, by calculating the
difference between the 1990 and 2015 age-standardised
prevalence. The statistical code is available on request from
the corresponding author. We investigated the attribution
of change in age-standardised vision impairment to three
factors, namely percentage change because of population
growth, population ageing after accounting for population
growth, and change in age-specific prevalence.
Estimation of functional presbyopia
To estimate the prevalence of near vision impairment
due to uncorrected presbyopia (functional presbyopia),
we included studies in which presbyopia was defined as
presenting near vision worse than N6 or N8 at 40 cm,
regardless of distance refractive status. For broad
estimates of vision impairment, including both distance
and near presenting impairment, we only included data
from people whose best-corrected visual acuity was
e891 www.thelancet.com/lancetgh Vol 5 September 2017
6/12 (20/40) or better, to avoid double counting those
with both distance and near vision impairment associated
with non-refractive causes. For most of the studies, the
prevalence of functional presbyopia was reported, as well
as data regarding near spectacle correction, the latter of
which we excluded. For other studies in which this
approach was not possible, we used presenting near
vision data if reported. For a multisite study that reported
presenting visual acuity for which we had access to
microdata,18,19 we included all participants with presenting
visual acuity worse than 6/12 at near vision and subtracted
the number of people with best-corrected visual acuity
worse than 6/12. All included studies only included
participants older than 35 years.
We developed a similar model to the main model used
for blindness and moderate and severe vision impairment.
We used a hierarchical generalised linear modelling
framework with a negative binomial observation model
and logistic link function. Because of data sparsity, we did
not include country-level covariates or indicators. The
model included an intercept term and random offsets for
ten age categories, 21 GBD regions, seven world super-
regions, and each study, in which each set of random
offsets was assigned a common Bayesian prior to enable
partial pooling.20 The age categories were given by 5-year
age bands, with an indicator variable for each age group
starting with 35–39 years, and then continuing by 5-year
age bands until a final age band of older than 80 years.
Observations that covered wider age bands were
incorporated by population-weighted averaging. For
example, for a study reporting prevalence for ages
35–44 years, the model’s predicted estimates for
35–39 years and 40–44 years were averaged on the basis of
the appropriate country-year population distribution, and
this average was then linked to the observed prevalence.
Forecasting the prevalence of blindness and vision
impairment
We applied our model to forecast prevalence of blindness
and moderate and severe vision impairment. These
forecasts projected possible scenarios rather than as fully
probabilistic forecasts, so we have not reported UIs. Our
model relies on health status and education as covariates.
Since it is impossible to predict how these will evolve
decades into the future, we extrapolated these covariates
to the year 2020 (appendix 1) and then held them constant
to 2050. Since our model gives estimates of crude
prevalence for country-years, we relied on the UN
Population Division’s forecasts to 2050 to derive crude
numbers affected and age-standardised prevalence.21
Thus, our estimates are also contingent on the
assumptions regarding future fertility and mortality that
underpin the UN Population Division’s estimates.
Role of the funding source
The funder of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of
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Stevens and colleagues2 New data sources

Western sub-Saharan Africa
Southern sub-Saharan Africa
Eastern sub-Saharan Africa
Central sub-Saharan Africa
Oceania
North America, high income
North Africa and Middle East
Tropical Latin America
Southern Latin America
Central Latin America
Andean Latin America
Western Europe
Eastern Europe
Central Europe
Caribbean
Australasia
Southeast Asia
South Asia
East Asia
Central Asia
Asia Pacific, high income 01

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Blind 1
Severe vision impairment 2
Moderate vision impairment 5
Mild vision impairment 10

Figure 1: Population-based prevalence studies of blindness and vision impairment in the Global Vision Database
Volume of new studies by region and reporting by vision loss severity are presented with a comparison to those in the original systematic review.8 New studies were obtained from Afghanistan,
Bhutan, Burundi, China, Egypt, Eritrea, Ethiopia, Ghana, Honduras, India, India, Iran, Jordan, Kenya, Laos, Libya, Madagascar, Moldova, Mozambique, Nepal, Nigeria, Norway, Panama, Saudi Arabia,
South Africa, South Korea, Taiwan, Tanzania, Timor-Leste, Turkey, Uganda, Vietnam, and Zambia. Black bubbles indicate the number of studies.

the report. The corresponding author had full access to
all the data in the study and had final responsibility for
the decision to submit for publication.
Results
In total, 61 new studies were added to the Global Vision
Database and included in the meta-analysis, giving a total
of 288 studies contributing data from 98 countries.2 The
volume of new studies by region and reporting by
blindness or vision impairment severity are illustrated in
figure 1, with comparison to those in the original
systematic review.7 Globally, of the 7·33 billion people
alive in 2015, 36·0 million (80% UI 12·9–65·4) were blind
(0·49%, 80% UI 0·18–0·89), of whom 20·1 million
(80% UI 7·1–36·8) were female (56%; table 2).
The largest number of blind people resided in south
Asia (11·7 million, 80% UI 4·1–21·7), followed by east
Asia (6·2 million, 2·1–11·5) and southeast Asia
(3·5 million, 1·3–6·3). The crude prevalence of blindness
ranged from 0·24% (80% UI 0·10–0·42) in Australasia
to 0·70% (0·24–1·29) in south Asia (appendix 1).
Moderate and severe vision impairment affected
216·6 (80% UI 98·5–359·1) million people (2·95%,
80% UI 1·34–4·89) of the global population, of whom
118·9 million (55%) were female. The largest number of
people with moderate to severe vision impairment also
resided in south Asia (61·2 million, 80% UI 29·6–98·6),
followed by east Asia (52·9 million, 23·2–89·6), and
southeast Asia (20·8 million, 9·8–33·9). The prevalence
of moderate and severe vision impairment varied
from 1·57% (80% UI 0·67–2·66) in southern
sub-Saharan Africa to 3·69% (1·62–6·25) in east Asia.
An estimated 188·5 (80% UI 64·5–350·2) million
people had mild vision impairment (2·57%, 80% UI
0·88–4·77), 101·4 million (54%) of whom were female.
Presenting functional presbyopia was estimated to
affect 1094·7 (80% UI 581·1–1686·5) million people aged
35 years and older, including 666·7 (364·9–997·6) million
people aged 50 years and older. The crude prevalence of
functional presbyopia was 35·6% (18·9–54·9) for people
aged 35 years and older, and 40·3% (22·0–60·4) for
people aged 50 years and older (appendix 1).
The burden of vision impairment was greatest in those
aged 50 years and older: 31 million (86%) of 36 million
blind people, 172·3 million (80%) of 216·6 million people
with moderate and severe vision impairment, 140·3 (74%)
of 188·5 million people with mild vision impairment,
and 666·7 (61%) of 1094·7 million people with functional
presbyopia were within this age category (table 2;
appendix 1).
Given the strong association of vision impairment with
age, prevalence of impairment varied by region because of

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 Articles
World Blind Moderate and severe vision impairment
population
(millions)
Prevalence (%) Number (millions) Prevalence (%)
Men
0–49 years 2920 0·08 (0·03–0·15) 2·46 (0·81–4·52) 0·74 (0·30–1·29)
50–69 years 613 0·93 (0·32–1·70) 5·69 (1·95–10·40) 6·78 (2·98–11·45)
≥70 years 169 4·55 (1·74–8·09) 7·72 (2·95–13·73) 20·33 (10·55–31·75)
Women
0–49 years 2780 0·09 (0·03–0·17) 2·56 (0·82–4·79) 0·82 (0·31–1·44)
50–69 years 634 1·03 (0·34–1·91) 6·52 (2·17–12·14) 7·48 (3·18–12·77)
≥70 years 222 4·97 (1·87–8·92) 11·06 (4·16–19·86) 21·87 (11·13–34·29)
Data are % (80% uncertainty interval) or number (80% uncertainty interval).
Table 2: Global numbers affected and crude prevalence of vision impairment by age and sex, 2015
differences in regional age structures, as well as other
differences. To compare patterns and trends in the
prevalence of vision impairment without being confounded
by the age structure, we calculated age-standardised
prevalence, focusing on older adults (aged ≥50 years), who
had the largest burden of vision impairment.
In 2015, the age-standardised prevalence of blindness
and moderate and severe vision impairment and mild
vision impairment among older adults was far higher in
some developing regions than in high-income regions
(figure 2; appendix 1). The prevalence of blindness in older
adults was 4% or greater in three developing regions in
2015: western sub-Saharan Africa (5·1%, 80% UI 2·0–8·9),
eastern sub-Saharan Africa (4·3%, 1·7–7·4), and south
Asia (4·0%, 1·5–7·3). By contrast, blindness prevalence
was 0·5% or less in all high-income regions (figure 2;
appendix 1). For moderate and severe vision impairment,
the age-standardised prevalence was highest in south Asia
(17·5%, 80% UI 9·1–27·2), North Africa and the Middle
East (17·2%, 8·6–26·8), western sub-Saharan Africa
(16·0%, 8·0–25·3), central sub-Saharan Africa (14·4%,
6·3–24·5), and southeast Asia (14·1%, 6·9–22·3).
Similarly, the prevalence of moderate and severe vision
impairment was lowest (<5·1%; highest 80% UI upper
bound 8·79%) in all four high-income regions, where it
was one-third that of south Asia (figure 2; appendix 1). The
age-standardised prevalence of mild vision impairment
was highest in south Asia (12·2%, 80% UI 4·9–21·2),
North Africa and the Middle East (11·9%, 4·7–20·5),
western sub-Saharan Africa (11·2%, 4·4–19·4), and central
sub-Saharan Africa (10·8%, 3·9–19·3). Mild vision
impairment prevalence was 5% or less in all four high-
income regions and in central Europe (figure 2; appendix 1).
Among the seven super-regions, the age-standardised
prevalence of functional presbyopia was highest in older
adults of south Asia (63·8%, 80% UI 50·9–76·6), sub-
Saharan Africa (58·5%, 42·6–73·8) and central Europe,
eastern Europe, and central Asia (51·9%, 22·3–81·3), and
lowest in the high-income super-region (12·2%, 3·6–24·8).
e893 www.thelancet.com/lancetgh Vol 5 September 2017
Mild vision impairment
Number (millions) Prevalence (%) Number (millions)
21·66 (8·67–37·61) 0·81 (0·21–1·62) 23·61 (6·20–47·21)
41·57 (18·30–70·23) 6·46 (2·14–12·26) 39·65 (13·10–75·21)
34·53 (17·91–53·92) 14·05 (6·05–23·47) 23·85 (10·28–39·86)
22·68 (8·65–39·97) 0·89 (0·23–1·79) 24·64 (6·30–49·70)
47·46 (20·18–80·99) 6·99 (2·30–13·29) 44·35 (14·59–84·27)
48·71 (24·79–76·35) 14·57 (6·28–24·23) 32·45 (13·99–53·95)
More women than men had vision impairment. When
controlling for age, within the constraints of residual
confounding due to longer survival of women and
hence over-representation in very high age groups, female
prevalence of blindness was greater than for men in all
world regions. The world female-to-male age-standardised
prevalence ratio among adults was 1·05 for blindness,
1·07 for moderate and severe vision impairment, and
1·05 for mild vision impairment.
The age-standardised prevalence of blindness in older
adults was highest, exceeding 7% in Afghanistan, then
Ethiopia, Yemen, Chad, Cameroon, and Niger
(appendix 2). The highest age-standardised prevalence of
moderate and severe vision impairment, which exceeded
21% in the older adult population, was in Afghanistan,
Nepal, Eritrea, Turkey, Laos, Pakistan, and Myanmar
(appendix 2).
The global age-standardised all-age prevalence of
blindness decreased from 0·75% (80% UI 0·25 to 1·41)
in 1990 to 0·48% (0·17 to 0·87) in 2015, a decrease of 0·27
(–0·61 to 0·00) percentage points in the age-specific
burden of disease (90% posterior probability of a true
decline). During the same time period, the global age-
standardised, all-age prevalence of moderate and severe
vision impairment decreased from 3·83% (1·66 to 6·42)
to 2·90% (1·31 to 4·80), a decrease of 0·93 (–2·29 to –0·43)
percentage points (83% posterior probability of a true
decline; appendix 1). The largest absolute decreases in
blindness prevalence occurred in North Africa and the
Middle East and south Asia (≥0·7 percentage points), and
in the same two regions plus the GBD super-region of
southeast Asia, east Asia, and Oceania for moderate and
severe vision impairment (all experienced declines of at
least 1·3 percentage points).
Between 1990 and 2015, the absolute number of blind
people increased by 17·9%, from 30·6 million in 1990 to
36·0 million in 2015. This increase was attributable to
three factors, namely percentage change because of
population growth (38·4%), population ageing after
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Blindness Moderate and severe vision impairment Mild vision impairment

Male Female Male Female Male Female

Asia Pacific, high income Western Europe Western Europe

Western Europe Asia Pacific, high income Asia Pacific, high income
Australasia North America, high income North America, high income
North America, high income Australasia Australasia
Southern Latin America Central Europe Central Europe
Central Europe Tropical Latin America Tropical Latin America
Eastern Europe Southern Latin America Southern Latin America
Tropical Latin America Eastern Europe Eastern Europe
East Asia Caribbean Caribbean
Central Asia Central Asia Central Asia
Central Latin America Central Latin America Central Latin America
World Southern sub-Saharan Africa Southern sub-Saharan Africa
Caribbean World World
Andean Latin America East Asia East Asia
Central sub-Saharan Africa Oceania Oceania
Southeast Asia Andean Latin America Eastern sub-Saharan Africa
Oceania Eastern sub-Saharan Africa Andean Latin America
Southern sub-Saharan Africa Central sub-Saharan Africa Central sub-Saharan Africa
North Africa and Middle East Southeast Asia Southeast Asia
South Asia Western sub-Saharan Africa Western sub-Saharan Africa
Eastern sub-Saharan Africa North Africa and Middle East North Africa and Middle East
Western sub-Saharan Africa South Asia South Asia

0 5 10 15 0 5 10 15 0 10 20 30 40 0 10 20 30 40 0 5 10 15 20 25 0 5 10 15 20 25
Age-standardised prevalence of blindness, Age-standardised prevalence of blindness, Age-standardised prevalence of mild vision
≥50 years (%) ≥50 years (%) impairment, ≥50 years (%)
High income Sub-Saharan Africa Latin America and Caribbean 2015
Asia North Africa and Middle East World 1990

Figure 2: Age-standardised prevalence of blindness, moderate and severe vision impairment, and mild vision impairment by subregion and sex for 2015, in adults aged 50 years and older

accounting for population growth (34·6%), and change Discussion

in age-specific prevalence (–36·7%). The number of In 2015, an estimated 36 million people were blind
people with moderate and severe vision impairment (visual acuity worse than 3/60), 217 million had moderate
similarly increased, from 159·9 million to or severe vision impairment (worse than 6/18 but 3/60 or
216·6 million (35·5%), and the proportion accounted for better), and 188 million had mild vision impairment
by each of these three factors were similar (38·4% increase (worse than 6/12 but 6/18 or better). Most people who
due to population growth, 29·2% increase due to were blind or who had moderate and severe vision
population ageing, and 24·2% decrease in age-specific impairment resided in south Asia, east Asia, and
prevalence). More detail about this global trend is given southeast Asia, whereas the age-standardised prevalence
in table 3. We also examined the change between 2010 of blindness was highest in western sub-Saharan Africa,
and 2015 for each of these three factors for blindness eastern sub-Saharan Africa, and south Asia. Although
(6·0%, 7·7%, and –7·3%, respectively) and moderate and sparsity of data for presbyopia prevented a meaningful
severe vision impairment (6·1%, 6·7%, and –3·9%, analysis of its prevalence in 2010, we could estimate that
respectively; data not shown). 666·7 million people aged 50 years and older and
We projected that an estimated 38·5 million people 1·09 billion people aged 35 years and older are affected
(80% UI 13·2–70·9; 0·50%, 80% UI 0·17–0·92) would be by near vision impairment due to uncorrected presbyopia.
blind in 2020 (of a total global population of 7·75 billion) Whereas we only presented a global estimate for mild
and 114·6 million people (23·39–229·0; 1·18%, vision impairment because of limited data sources
0·24–2·36) people would be blind in 2050 (of a total global in 2010, the advent of more recently published data for
population of 9·69 billion). For moderate and severe this category means we can now present more detailed
vision impairment, the estimates were 237·1 million regional estimates for this disability, which has an impact
people (101·5–399·0; 3·06%, 1·31–5·15) in 2020 and on quality of life.
587·6 million people (155·9–1093·8; 6·06%, 1·61–11·29) The interval improvement (in terms of a reduction in
in 2050. Global predictions of numbers of people who will age-standardised prevalence of distance vision
be blind or moderately or severely vision impaired, for impairment) since 1990 and since 2010, after accounting
each decade between 2020–50, are shown in figure 3. for population growth and ageing, suggests that modest

www.thelancet.com/lancetgh Vol 5 September 2017 e894

 Articles
Number of people in 1990 (millions)
Number expected with 2015 population,
1990 population age structure, and 1990
prevalence (millions)
Number expected with 2015 population,
2015 population age structure, and 1990
prevalence (millions)
Number of people in 2015 (millions)
Change from 1990 because of population
growth (%)
Change from 1990 because of population
ageing (having already included
population growth, %)
Change from 1990 because of change
in age-specific prevalence (%)
Change from 1990 to 2015
Table 3: Global trends in numbers of people blind or visually impaired,
1990–2015
600 Moderately or severely vision impaired
Blind
500
Number affected (millions)
400
300
200
100
0 some of these root causes would be responsible for the
1990 2000 2010
Figure 3: Global trends and predictions of numbers of people who are blind
or moderately and severely vision impaired, from 1990–2050
investments that were made in the alleviation of
impairment during this period have reaped considerable
dividends. Such dividends include improvements in
quality of life and large economic benefits, because
people work rather than living with or caring for those
living with unnecessary vision impairment.22,23
For more on the RAAB Although this study does not directly assess the causes of
online repository see vision impairment, the large disparities between regions—
http://www.raabdata.info
as well as results from previous reports that directly
addressed the question24—suggest that most cases of
vision impairment in lesser-developed countries could be
prevented or reversed. Although additional alleviation
efforts will be needed everywhere, the regions with the
largest prevalence and absolute burden of vision
impairment should receive targeted attention. Given that a
large proportion of blindness or vision impairment will
require individual-level care by trained practitioners, areas
such as those in sub-Saharan Africa with high age-
standardised prevalence of vision impairment and younger
population age structures represent particularly important
e895 www.thelancet.com/lancetgh Vol 5 September 2017
places in which to scale up training, in preparation for the
Blind Moderate and
severe vision predicted demographic expansion in older age groups.
impairment The growth and change in age structure of the world’s
30·6 159·9 population is causing a substantial increase in the
42·3 221·3 number of people with blindness and vision impairment,
which appears to be accelerating. Concurrently, the
observed decline in crude prevalence appears to be
56·9 285·9 becoming less marked, particularly with regard to severe,
moderate, and mild vision impairment. Although there
are limitations to the modelling projections, the projected
36·0 216·6
increase in prevalence and the global numbers affected
38·4% 38·4%
by blindness and vision impairment, for example the
34·6% 29·2% numbers of blind people increasing to 38·5 million
by 2020 and 115 million by 2050, indicates the scale of the
challenge. The observed reductions in age-standardised
–36·7% –24·2% prevalence of visual impairment in areas that received
modest investments in blindness alleviation suggest that
17·9% 35·5%
further investment is likely to mitigate these trends.
The finding that women bear the majority of blindness
and vision impairment in population-based studies has
been widely reported. A review of inequity in vision loss25
concluded that insufficient data for analysis of inequality
remains a problem in eye care and highlights the need for
equity-relevant goals, targets, and indicators for eye health-
care programmes. There are many other reasons for health
inequality between population groups, between and within
countries, which could include unfair distribution of
power and resources and global governance dysfunction,
these factors being judged as root causes in recent reports
by the Commissions on Social Determinants of Health
and the recent Global Governance for Health.26,27 Doubtless,
2020 2030 2040 2050
Year
considerable variation in crude and age-standardised
prevalence of blindness and vision impairment that we
observed between countries, and the very high prevalence
of older adult blindness in Afghanistan, Ethiopia, Yemen,
Chad, Cameroon, and Niger.
Since 2010, we have added 61 new studies reporting
distance vision impairment to the Global Vision Database,
the dataset that underpins these analyses. Several principal
investigators have contributed more disaggregated data
than was available in their previous publications, which
have been added to the Global Vision Database.
Additionally, the expansion of Rapid Assessment of
Avoidable Blindness population-based eye surveys and the
recently created online repository for these data have been
a valuable contribution and resource for the Global Vision
Database. Most studies that were newly added originated
from east Asia, south Asia, North Africa and the Middle
East, and east sub-Saharan Africa, whereas only a few new
studies came from high-income North America, Latin
America, Europe, and Australasia. In view of all available
data, gaps are still present for central and southern Sub-
Saharan Africa, eastern and central Europe, central Asia,
and the Caribbean (figure 1).
Limitations of our study have to be taken into account.
First, the availability of data sources varied between the

world regions, with major gaps as described previously.
Second, the studies underlying our meta-analysis have
varied definitions of blindness and vision impairment.
Although we statistically corrected for differences
between the studies, this difference increased the
uncertainty of the estimates. We appeal for a worldwide
reporting standardisation of definitions of blindness and
vision impairment.28 For instance, under-corrected
presbyopia, until recently, has mostly been neglected,
even in major population-based studies in ophthalmology,
with the result that precision of estimates is weaker.
Specifically, in terms of studies involving uncorrected
presbyopia, there are limitations that involve differences
between studies in which some measure objective and
others functional presbyopia, with differences in test
distance and font size. Fourth, many studies were not
done on a national level. Although we took into account
the level of representativeness of the data in the statistical
model, for many countries only regionally assessed data
on blindness and vision impairment were available.
Although the so-called national level is arbitrary, it is a
natural level for ascertainment of vision impairment
burden since policy is typically made at a national level.
Fifth, most underlying population-based studies included
only participants who could access the examination
centre whereas institutionalised (often elderly) individuals
usually did not fully participate in the studies. This
dynamic could have biased blindness and vision
impairment estimates downward, since many eye
diseases are age-related.29,30 Sixth, caution must be
exercised in the interpretation of the forecast of blindness
and vision impairment. For example, it is assumed that
the UN population projections for the future21 are correct
and that the covariates that we used in our model for
access to health care13 and literacy,12 which have not been
modelled into the future, will remain unchanged after
2015. Clearly, the level of provision of services will not
remain the same, especially in areas such as cataract
surgery and spectacles correction, but it is difficult to
forecast what these changes will be.
By contrast with the previous modelling approach we
took for 2010 estimates,2 we have taken a fully Bayesian
inference approach to modelling and posterior inference
in this analysis. We used Markov chain Monte Carlo
methods to fit our model, thus obtaining full posterior
distributions for all parameters and quantities of interest
(eg, age-standardised prevalence in a given country-year
and change in prevalence from 1990 to 2015). We sum­
marised these distributions by reporting 80% posterior
uncertainty intervals surrounding the mean, rather than
bootstrapped confidence intervals, as previously
reported.2 In the Bayesian framework, these uncertainty
intervals reflect our probabilistic belief (posterior
credibility) in our posterior mean predictions. Our
models also changed slightly from the previous
publication because we followed the 2015 GBD’s slightly
revised regional groupings.
www.thelancet.com/lancetgh Vol 5 September 2017 e896
Articles
Vision interventions provide some of the largest
returns on investment31 and are some of the most feasibly
implemented interventions in less developed areas
because of limited needs for infrastructure, lower costs,
and relatively high potential for cost recovery in certain
subdomains (eg, cataract surgery), compared with other
health interventions. Although this report substantiates
the ongoing reduction in the age-standardised prevalence
of blindness and vision impairment noted in 2010, the
growth and ageing of the world’s population is causing a
substantial increase in the number of people with
blindness and vision impairment, which appears to be
accelerating. These observations highlight the need to
respond to WHO’s Global Action Plan by scale-up of our
current efforts at global, regional, and country levels, to
eliminate the burden of unnecessary blindness and
vision impairment.
Contributors
RRAB, MVC, AD, AS, NT, and TB prepared the vision impairment
survey data. SRF, GAS, and RRAB analysed the data. RRAB and SRF
wrote the first draft of the report. All authors contributed to the study
design, analysis, and writing of the report. RRAB oversaw the research.
Vision Loss Expert Group
Rupert R A Bourne (Anglia Ruskin University, Cambridge, UK);
Peter Ackland (International Agency for Prevention of Blindness,
London, UK); Aries Arditi (Visibility Metrics LLC, New York, NY, USA);
Yaniv Barkana (Assaf Harofe Medical Center, Zerifin, Israel);
Banu Bozkurt (Department of Ophthalmology, Meram Medical Faculty,
Selcuk University, Konya, Turkey); Tasanee Braithwaite and
Richard Wormald (Moorfields Eye Hospital, London, UK); Alain Bron
(Service d’Ophtalmologie CHU, Dijon, France); Donald Budenz
(University of Miami, Miami, FL, USA); Feng Cai (Green-Valley Group,
Freedom, CA, USA); Robert Casson (University of Adelaide, Adelaide,
SA, Australia); Usha Chakravarthy, Nathan Congdon, and Tunde Peto
(The Queen’s University of Belfast, Belfast, Northern Ireland, UK);
Jaewan Choi (Hangil Eye Hospital, Incheon, South Korea);
Maria Vittoria Cicinelli (San Raffaele Scientific Institute, Milan, Italy);
Reza Dana and Maria Palaiou (Harvard Medical School, Boston, MA,
USA); Rakhi Dandona (George Institute for International Health,
Sydney, NSW, Australia); Lalit Dandona and Tueng Shen (University of
Washington, Seattle, WA, USA); Aditi Das (St James’s University
Hospital, Leeds, UK); Iva Dekaris (Eye Clinic Svjetlost, Zagreb, Croatia);
Monte Del Monte (University of Michigan, Ann Arbor, MI, USA),
Jenny Deva (Universiti Tunku Abdul Rahman, Kampar, Malaysia),
Laura Dreer and Marcela Frazier (University of Alabama, Birmingham,
AL, USA); Leon Ellwein and James Hejtmancik (National Eye Institute,
Bethesda, MD, USA), Kevin Frick, David Friedman, Jonathan Javitt,
Beatriz Munoz, Harry Quigley, Pradeep Ramulu, Alan Robin,
James Tielsch, and Sheila West (Johns Hopkins University, Baltimore,
MD, USA); Joao Furtado (University of São Paulo, São Paulo, Brazil);
Hua Gao (Henry Ford Medical Center, Michigan, MI, USA);
Gus Gazzard (UCL Institute of Ophthalmology, London, UK);
Ronnie George (Medical Research Foundation, Chennai, India);
Stephen Gichuhi (University of Nairobi, Nairobi, Kenya); Victor
Gonzalez (Valley Retina Institute, TX, USA); Billy Hammond (University
of Georgia, Athens, GA, USA); Mary Elizabeth Hartnett (University of
Utah, Salt Lake City, UT, USA); Minguang He, Tien Wong, and
Hugh Taylor (University of Melbourne, Melbourne, VIC, Australia);
Flavio Hirai (Federal University of São Paulo, São Paulo, Brazil);
John Huang (Yale University, New Haven, CT, USA); April Ingram
(Alberta Children’s Hospital, Calgary, AB, Canada); Jost Jonas
(Department of Ophthalmology, Medical Faculty Mannheim, Heidelberg
University, Mannheim, Germany); Charlotte Joslin (University of
Illinois, Chicago, IL, USA); Jill Keeffe and Rohit Khanna (L V Prasad Eye
Institute, Hyderabad, India); John Kempen and Dwight Stambolian
(University of Pennsylvania, Philadelphia, PA, USA); Moncef Khairallah
 Articles
(University Hospital Monastir, Tunisia); Judy Kim (Medical College of
Wisconsin, Milwaukee, WI, USA); George Lambrou (Novartis, Basel,
Switzerland); Van Charles Lansingh (HelpMeSee, Inc, New York, NY,
USA); Paolo Lanzetta (Department of Ophthalmology, University of
Udine, Udine, Italy); Janet Leasher (Nova Southeastern University, FL,
USA); Jennifer Lim (University of Illinois, Urbana, IL, USA);
Hans Limburg (Health Information Services, Grootebroek,
Netherlands); Kaweh Mansouri (Clinique De Montchoisi, Lausanne,
Switzerland); Anu Mathew (Royal Children’s Hospital, Melbourne, VIC,
Australia); Alan Morse (Jewish Guild Healthcare, New York, NY, USA);
David Musch (University of Michigan, Ann Arbor, MI, USA);
Kovin Naidoo (University of KwaZulu-Natal, Durban, South Africa);
Vinay Nangia (Suraj Eye Institute, Nagpur, India); Maurizio Battaglia
(Parodi University Vita Salute, Ospedale San Raffaele, Milan, Italy);
Fernando Yaacov (Pena Fundacion Vision, Asuncion, Paraguay);
Konrad Pesudovs (Flinders University, Adelaide, SA, Australia);
Murugesan Raju (University of Missouri, Columbia, MO, USA);
Serge Resnikoff (Brien Holden Vision Institute, Sydney, NSW, Australia);
Luca Rossetti (University of Milan, Milan, Italy); Jinan Saaddine
(National Center for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta, GA, USA);
Mya Sandar (Singapore Eye Research Institute, Singapore); Janet Serle
(Mt Sinai School of Medicine, New York, NY, USA); Rajesh Shetty (Mayo
Clinic, Minnesota, MN, USA); Pamela Sieving (National Institutes of
Health, Bethesda, MD, USA); Juan Carlos Silva (Pan-American Health
Organization, Columbia); Alex Silvester (Royal Liverpool University
Hospital, Liverpool, UK); Rita S Sitorus (University of Indonesia, Depok,
Indonesia); Gretchen Stevens (World Health Organization, Geneva,
Switzerland); Jaime Tejedor (Hospital Raman y Cajal, Madrid, Spain);
Miltiadis Tsilimbaris (University of Crete Medical School, Crete, Greece);
Jan van Meurs (The Rotterdam Eye Hospital and Erasmus University,
Rotterdam, Netherlands); Rohit Varma (University of Southern
California, CA, USA); Gianni Virgili (University of Florence, Italy);
Jimmy Volmink (Stellenbosch University, South Africa); Ya Xing (Wang
Capital Medical University, Beijing, China); Ning-Li Wang (Eye Centre of
Beijing Tongren Hospital, Beijing, China); Peter Wiedemann (Leipzig
University, Leipzig, Germany); and Yingfeng Zheng (Singapore Eye
Research Institute, Singapore)
Declaration of interests
We declare no competing interests.
Acknowledgments
GAS is a staff member of the World Health Organization. The author
alone is responsible for the views expressed in this publication and they
do not necessarily represent the decisions, policy, or views of the World
Health Organization.
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